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To the Editor:

Rheumatoid arthritis (RA) is the most frequent chronic inflammatory disease affecting approximately 1% of the white population, particularly females (3 times more often than males) (1). Because of its articular and extraarticular manifestations and complications, such as infections and osteoporosis, RA has a considerable impact on a patient's quality of life, with mayor physical, psychological, and social consequences. Treatment of RA includes not only medications but also education and cognitive-behavioral interventions (2). Recently, Riemsma et al described the impact of the use of education as a therapeutic tool in patients with RA (3). These authors proposed a categorization of educational practices into information only, counseling, and behavioral therapy. This approach is important because it emphasizes the various types of educational systems and allows analysis of data more objectively to avoid comparisons of unrelated interventions. Surprisingly, Riemsma's results indicated only a modest and short-term effect of education on RA patients, including global assessment, psychological status, and general well being (3). However, education may not only be important for the psychological well being of the patients but also for improving their adherence to therapy and for guiding patient's participation on therapeutic decisions. Indeed, adherence tends to be higher in patients who have participated in educational programs (4, 5). Moreover, the trend toward a favorable effect of education on depression may warrant its use as a therapeutic tool in patients with RA due to its known association with adherence (6).

The clinical expression of RA varies among populations and is influenced by several factors, including race, genetics, environmental factors, and access to medical care (7). Disability is one of the most important consequences of RA and is not free from the influence of sociocultural factors, such as attitudes towards health, illness, the patient's sociocultural level (8). Physicians should be aware of these factors before extrapolating findings on RA populations different from their own. In addition, RA treatment and outcome are better managed by rheumatologists than by other physicians (9).

The state of Antioquia (capital, Medellín) is geographically located in northwestern Colombia between the central and western branches of the Andean Mountains and has a population of 4,500,000. A large number of patients in this area do not know which physician should manage their illness, and access to specialized rheumatology care is limited by the restriction of social security laws, as well as by the low number (only 11) of rheumatologists in practice. A sizeable number of patients are treated with alternative medicine while others have no treatment at all.

We wanted to explore the general knowledge about RA of patients attending our rheumatology unit, as well as that of the general population. To that purpose, we surveyed 448 RA patients and 269 healthy individuals, using a 10-point questionnaire on RA knowledge (10) (Table 1). The questionnaire had been validated with a pilot study and through construct validity analyses (11). Patients with RA knew more about the disease's symptoms than healthy persons but the latter had more knowledge concerning prognosis and therapy than the patients. There were no significant differences in knowledge about the etiology of disease in these 2 groups.

Table 1. Level of knowledge about rheumatoid arthritis (RA) in patients compared with the general population (no RA)
CharacteristicRA (n = 448)No RA (n = 269)
  • *

    According to the Colombian socioeconomic classification.

  • P < 0.01 after adjusting for age and education level.

Sex, male:female44:40240:227
Age, years, mean ± SD54 ± 1349.3 ± 16
Education, %  
 None21
 Primary school3826
 High school3532
 Technical1314
 University1022
 Postgraduate25
Socioeconomic status, %*  
 22925
 34444
 41416
Correct answers to true or false questions, %  
1.There is only a single therapy for all RA patients (Existe un tratamiento único para los pacientes con artritis reumatoidea)5868
2.All RA patients have a bad prognosis (Todos los pacientes con artritis reumatoidea tienen un mal pronóstico)4358
3.The neck is the most commonly affected area of the spine in patients with RA (El cuello es la parte de la columna que se afecta mas comúnmente en los pacientes con artritis reumatoidea)3827
4.RA is caused by cold weather, inadequate nourishment and humidity (La artritis reumatoidea es causada por la mala alimentación, el frío y el clima húmedo)5659
5.Patients with RA should not play a role in the management of their disease because the physician is the one in charge (Los pacientes con artritis reumatoidea no deben asumir un papel muy activo en su proceso de recuperación porque el médico es el encargado principal)5964
6.RA and osteoporosis are the same disease (Artritis y osteoporosis son la misma enfermedad)8085
7.RA can produce dryness in the eyes and mouth (La artritis reumatoidea puede causar resequedad en los ojos y en la boca)5233
8.Patients with RA should include all kinds of food in their meals but must avoid meat (Los pacientes con artritis reumatoidea deben incluir en su dieta alimentos variados pero no deben comer carnes rojas)3330
9.RA never compromises the lungs (La artritis reumatoidea nunca afecta los pulmones)2631
10.To confirm the diagnosis of RA, it is necessary to perform some blood tests (Para confirmar el diagnóstico de artritis reumatoidea es necesario hacer algunos exámenes de sangre)8775
More than 6 correct answers, %4748
Number of correct answers, mean ± SD4.97 ± 2.315 ± 2.36

The poor knowledge about RA in both patients and the general population, and the finding that patients had the same level of knowledge as the general population, suggest that educational programs are sorely needed to provide adequate and rational information on RA. This opens the discussion concerning the need to balance the importance of education as a therapeutic tool, and the ethical and social implications of providing education in an environment where managed care and cost-benefit issues are the prevailing forces.

  • 1
    Lawrence RC, Helmick CG, Arnett FC, Deyo RA, Felson DT, Giannini EH, et al. Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States. Arthritis Rheum 1998; 41: 77899.
  • 2
    American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines. Guidelines for the management of rheumatoid arthritis, 2002 update. Arthritis Rheum 2002; 46: 32846.
  • 3
    Riemsma RP, Kirwan JR, Taal E, Rasker JJ. Patient education for adults with rheumatoid arthitis. Cochrane Database Syst Rev 2002; 3: CD003688.
  • 4
    Hill J, Bird H, Johnson S. Effect of patient education on adherence to drug treatment for rheumatoid arthritis: a randomised controlled trial. Ann Rheum Dis 2001; 60: 86975.
  • 5
    Viller F, Guillemin F, Briancon S, Moum T, Suurmeijer T, van den Heuvel W. Compliance to drug treatment of patients with rheumatoid arthritis: a 3 year longitudinal study. J Rheumatol 1999; 26: 211422.
  • 6
    DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med 2000; 160: 21017.
  • 7
    Anaya JM, Correa PA, Mantilla RD, Jimenez F, Kuffner T, McNicholl JM. Rheumatoid artritis in African Colombians from Quibdo. Semin Arthritis Rheum 2001; 31: 1918.
  • 8
    Escalante A, del Rincón I. The disablement process in rheumatoid arthritis. Arthritis Rheum 2002; 47: 33342.
  • 9
    Emery P, Breedveld FC, Dougados M, Kalden JR, Schiff MH, Smolen JS. Early referral recommendation for newly diagnosed rheumatoid arthritis: evidence based development of a clinical guide. Ann Rheum Dis 2002; 61: 2907.
  • 10
    Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Cooper NS, et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum 1988; 31: 31524.
  • 11
    Cadena J, Alvarez A, Correa M, Bonilla LM, Gómez MP, Montoya MA, et al. Encuesta de conocimiento sobre artritis reumatoidea: ¿vale la pena educar? Rev Colomb Reumatol 2002; 9: 2629.

Jose Cadena MD*, Juan-Manuel Anaya MD*, * Universidad Pontificia Bolivariana, Medellín, Colombia.